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NEW YORK STATE DEPARTMENT OF HEALTH Merger-Acquisition Division of Finance and Rate Setting HEALTH CARE REFORM ACT PUBLIC GOODS POOL DOH-4406 INSTRUCTIONS Name of Acquiring Company/ Federal ID Number Enter legal name of acquiring company and their federal employer identification number FEIN. Enter date all NY claims were adjudicated. Is the Acquiring Company a Participant as an Elector in the NYS Public Goods Pool Check the appropriate box yes o...

How to fill out doh 4406 - health

How to fill out DOH 4406:

1. Gather the necessary information: Before starting to fill out DOH 4406, make sure you have all the required information such as the patient's name, date of birth, address, and any relevant medical history.
2. Section 1: Personal Information: Start by accurately filling out the patient's personal information in section 1 of the form. This includes their full name, date of birth, gender, address, and contact details.
3. Section 2: Medical History: In this section, provide a detailed medical history of the patient. Include any past illnesses, allergies, surgeries, or chronic conditions that the patient has experienced. It is crucial to be thorough and provide accurate information to ensure proper medical care.
4. Section 3: Current Medications: List all the medications (prescription and over-the-counter) that the patient is currently taking. Include the name of the medication, dosage, frequency, and the reason for taking it. This information helps healthcare professionals make informed decisions regarding the patient's treatment.
5. Section 4: Vaccination History: Fill out this section by documenting the patient's vaccination history. Include the type of vaccine, date received, and any associated reactions or allergies. This information is critical for tracking the patient's immunization status.
6. Section 5: Parent/Guardian/Caregiver Information: If the patient is a minor or has a legal guardian or caregiver, provide their information in this section. Include their full name, relationship to the patient, contact details, and any additional relevant information.
7. Section 6: Consent for Disclosure: This section is where the patient or their legal representative gives consent for the release of the information provided on the form to authorized entities. Read the consent statement carefully and sign accordingly.

Who needs DOH 4406:

DOH 4406 is typically required by healthcare providers, such as doctors, nurses, and hospitals, in order to collect accurate and comprehensive patient information. It is especially important for new patients or those seeking medical attention for the first time. The form helps healthcare professionals have a clear understanding of the patient's medical history, current medications, and vaccination status. This information plays a crucial role in ensuring safe and effective medical care.

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What is doh 4406?

Doh 4406 is a form used for reporting certain information to the Department of Health.

Who is required to file doh 4406?

Healthcare facilities and organizations are required to file doh 4406.

How to fill out doh 4406?

Doh 4406 can be filled out online or by mail, following the instructions provided by the Department of Health.

What is the purpose of doh 4406?

The purpose of doh 4406 is to collect data on healthcare facilities and organizations for regulatory purposes.

What information must be reported on doh 4406?

Information such as facility details, staffing levels, patient statistics, and financial data must be reported on doh 4406.